Provider Demographics
NPI:1962795583
Name:PROVOST, ANDREW J (MSPT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:PROVOST
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRAINTREE ST ST
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-1956
Mailing Address - Country:US
Mailing Address - Phone:617-787-8700
Mailing Address - Fax:617-787-8106
Practice Address - Street 1:1 BRAINTREE ST ST
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-1956
Practice Address - Country:US
Practice Address - Phone:617-787-8700
Practice Address - Fax:617-787-8106
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist